Adoption Application

All information is important so please be as accurate as possible. All questions must be answered. If a question does not apply to your situation, type Not Applicable. Use the TAB key to move to the next question. Do not press the ENTER key. When you have completed all fields, read the conditions statements and type your name in the signature box. You can scroll back up through the form to make sure all boxes are filled. Then click SUBMIT at the bottom left portion of the screen. You should see a message indicating you have successfully submitted your application.

If after submitting you still see the form on your screen, you have missed one or more questions. Scroll through the form to find any red statements appearing above an empty box and fill in the empty box. Once you have successfully completed all boxes, type your name in the signature box at the bottom and clicked on SUBMIT. If you have continued difficulty with the online application, you may contact Sandra Wendt for assistance with form completion. Her email is: president@uyr.us.

Last Name:

First Name:

Email Address:

Date of Birth:

Address:

City:

State:

Zip:

How long have you been at this address:

Prior address if less than 2 years:

How long were you at previous address:

Home Phone:

Best time to reach at home:

Work Phone:

Alternative Phone:

Employer:

Occupation:

Spouse or Partner Name:

Spouse or Partner Date of Birth:

Spouse or Partner Occupation:

Number of children living in your home:

This data is very important to us. Please be as specific as possible.

Ages and Relation to you:

Do you have young children visit regularly:

This data is very important to us. Please be as specific as possible.

Their ages and relation to you:

Please list everyone in your home not mentioned above, relation to you, and their ages:

Living Environment (must be completed in it's entirety)

Please select the term(s) that best describe your current living situation:

HouseCondoApartmentModular Home

Home ownership:

Social Environment:

Does your home have a backyard:

Is your backyard fenced:

Fence Type?:

Fence Height:

Is fence permanent:

Is the edge of the fence buried to prevent tunneling:

Will the gate be padlocked:

Do you have a pool or pond:

If so, please explain precautions taken to keep pets out of drowning danger:

Adoption and Care Information (must be completed in it's entirety)

Why do you want to adopt a yorkie:

What do you know about the yorkie breed as to temperament, health, etc:

Is everyone in your home agreeable to adopting a yorkie:

If not, who and why not:

Is there a specific dog you are interested in adopting:

If the above dog isn't available, do you have a second choice:

Where did you first see the dog you are interested in adopting?:

If the dog you wish is not fostered in your state, will you bear the responsibility and cost for flying to pick up the dog if you are approved?:

Preference for male or female:

Do you have an age preference, specify:

Will your adopted yorkie be left alone:

If so, for how long:

Will you attend obedience training:

Trainer's name:

Specifically, what will the yorkie's living situation:

If outside, describe kennel, house, etc:

Is it:

HeatedCooledN/A

What activities are you going to engage in with your yorkie:

How long will you keep this yorkie:

Under what circumstances would you give up this yorkie:

Current & Previous Pets

Have you ever owned a yorkie:

If so, where is it now:

Do you have other pets:

Please list age, sex, and species:

Are all pet(s) current on vaccinations:

Are all pet(s) spayed/neutered:

If no to either, which pet(s) and why:

Are all pets(s) on heartworm preventative:

Brand of heartworm preventative:

If not, please explain:

Approximate date of last vet visit for each pet:

Name of person dog's vet file is under:

Have any of your current pets shown aggression or bitten a person:

If yes, please explain the circumstances of the agression toward a person:

Have any of your current pets ever shown aggression or bitten a pet:

If yes, please explain the circumstances of the agression toward a pet:

Please list all other pets you have owned in the last 10 years not mentioned above and where they are now:

We will provide you with an evaluation of the foster Yorkshire Terrier's temperament based on the information provided to us by the surrendering owner or information provided by the shelter where the yorkie came from.

Do you understand that often times the complete history of a rescue Yorkshire Terrier may not be known:

Will you be willing to work with us to correct any possible behavior problems:

References

Veterinarian name, address, and phone number:

Vet fax number:

Secondary vet name and any other vet you may have seen in the last 5 years, address, and phone number:

Groomer name, address, and phone number:

Please provide the name, address, and telephone number of three (3) references and their relationship to you.Please only include one (1) family member.

Reference 1:

Reference 2:

Reference 3:

Read the following carefully

I declare that the information I have provided in this application is complete and correct. I understand that any false information I have provided will invalidate this and any future applications. I further declare that I am 25 years of age or more and am financially and physically able to care for a rescued dog. I understand that proper food and veterinarian care may be costly, and I am able and willing to meet the needs of my adoptive dog. I understand the requirements and grant permission for Home Checks at random, both prior to and following adoption. I submit that if a Home Check reveals falsification or misrepresentation of any facts on my part, United Yorkie Rescue reserves the right to either refuse adoption or to nullify the adoption and reclaim said dog from my premises without reimbursement of the adoption donation. I release United Yorkie Rescue from any liabilities I may incur from the adoption process.

Applicant's signature:

Before proceeding, please note adopters must be age 25 or over. All information is important so please be as accurate as possible. All questions must be answered. If a question does not apply to your situation, type Not Applicable. Use the TAB key to move to the next question. Do not press the ENTER key. When you have completed all fields, read the conditions statements and type your name in the signature box. You can scroll back up through the form to make sure all boxes are filled. Then click SUBMIT at the bottom left portion of the screen. You should see a message indicating you have successfully submitted your application.

If after submitting you still see the form on your screen, you have missed one or more questions. Scroll through the form to find any red statements appearing above an empty box and fill in the empty box. Once you have successfully completed all boxes, type your name in the signature box at the bottom and clicked on SUBMIT. If you have continued difficulty with the online application, you may contact the foster parent of the dog you are applying for and request they help you submit your application.